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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 392701285
Report Date: 06/20/2024
Date Signed: 06/24/2024 12:21:10 PM

Document Has Been Signed on 06/24/2024 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:GATE OF BEAUTIFUL RIPON, THEFACILITY NUMBER:
392701285
ADMINISTRATOR/
DIRECTOR:		ELL, NICOLEFACILITY TYPE:
740
ADDRESS:836 SUNRISE AVETELEPHONE:
(209) 614-5171
CITY:RIPONSTATE: CAZIP CODE:
95366
CAPACITY: 6CENSUS: 0DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Nicole EllTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Unannounced annual visit made out to this facility on 06/20/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator, Nicole Ell, who was briefly interviewed.
It was learned that there weren't any residents under the care of hospice at this time.
It was learned that there weren't any residents who were receiving services through home health at this time.
This facility does have a hospice waiver approved to accept and retain up to (6) residents at any given time.
This facility also has, on file, a program to accept and retain residents diagnosed with dementia at this time.
Current census was 0 residents.
A tour of this facility was conducted.
Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Nicole Ell. Forms and documents were submitted to renew for Certificate #6019506740 that was set to expire on 08/16/2024.
Kitchen area was toured. Cabinets and drawers were reviewed. Food preparation stations, dishwashing station, and other areas intended for meal preps were toured.
Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. This LPA did observe additional food storage units which were present and functional at this time.
A tour of the dining area, living area, and all other areas intended for resident use was conducted.
Medication cabinet, located in hallway closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications were discussed with the facility designated Administrator at this time. The medication cabinet was observed to be locked and made inaccessible to the residents at this time.
A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time.
Grab bars and non skid mats were observed to be present and in good repair at this time.
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 06/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: GATE OF BEAUTIFUL RIPON, THE
FACILITY NUMBER: 392701285
VISIT DATE: 06/20/2024
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Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees.
Linen closet, located in the facility hallway, was observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.
Fire extinguishers, located throughout this facility, were observed to have been annually purchased on 06/20/2024 from the hardware store with receipts attached and in compliance at this time.
First aid kit was observed to be present and contained all of the required components at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gates, and exits was conducted.

A review of the facility resident files was not conducted since there weren't any residents in care at this time.
A review of (1) facility personnel file was conducted and noted on the following LIC 859.

The following forms and documents were requested to be updated and submitted into CCL:
  • LIC 308

  • LIC 400

  • LIC 500

  • LIC 610


There were no deficiencies observed or cited during today's annual visit.

Exit Interview
SUPERVISORS NAME: Liza King
LICENSING EVALUATOR NAME: Charlie Yang
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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